2010 Model Practice Application (Public)

Getting Medicine to Priority Groups: 2009 H1N1 Vaccine Administration Phase 1

Dallas County Health and Human Services

The Dallas County 2009 H1N1 Vaccine Administration Phase 1, implemented in October 2009, addressed the need to administer H1N1 vaccine to Dallas County residents. Specifically, this practice provided an opportunity for the health department to operate a mass clinic and test DCHHS continuity of operations during a mass vaccination clinic. The targeted population was the priority groups outlined by Centers for Disease Control and Prevention: persons six months to 24 years old, adults with underlying medical conditions, pregnant women, healthcare workers and persons who interact with infants six months or younger. Dallas County, being the lead agency to protect the health of the citizens of Dallas County, sponsored a three-day H1N1 public mass clinic. The 2009 H1N1 Administration Phase 1 is the first approach to how DCHHS responded to the administration of vaccines during this 2009 influenza season. In November 2009, the health department utilized its facility as the mass clinic site and implemented phase 1 of its multifaceted approach to administering H1N1 influenza vaccines while accomplishing the following objectives: 1) Over a period of three days, administer the H1N1 vaccine to 10,000 Dallas County residents, 2) Continue the essential delivery of public health services as it contributes to the continuity of operations for Dallas County communities, and 3) Utilize three adjoining rooms, located on the sixth floor of the local health department’s facility, to conduct H1N1 mass vaccination Overall, DCHHS planned, managed, operated, and hosted a mass vaccination clinic, during normal business hours, by using its available physical space. This practice has produce three outcomes critical to DCHHS continuity of operation during emergency circumstances: 1) enabling a rapid response to any emergency situation during normal operations 2) relying on trained and cross-trained internal resources to perform roles and responsibilities in a vaccination clinic, and 3) testing the ability of DCHHS to function and provide continuous vital services.

In July 2009, CDC announced its recommendations for use of vaccine against novel influenza A (H1N1). The targeted population outlined by Centers for Disease Control and Prevention included: persons six months to 24 years old, adults with underlying medical conditions, pregnant women, health care workers and persons who interact with infants 6 months or younger. These recommendations lead to the initial step in planning prevention and preparedness efforts for the 2009 H1N1 influenza season. The combination of H1N1 vaccination administration and children’s immunization compliance created a difficult task for DCHHS. Traditionally, Dallas County Health and Human Services conducts vaccination for seasonal flu in its Adult Immunization/Foreign Travel Clinic or Childhood Immunization Clinic. Each clinic is capable of servicing an estimate of 100 Dallas County residents on a daily basis. Because the mass majority of the high-risk individuals needing vaccination would visit the children’s clinic, the H1N1 vaccination event would impede their ability to maintain normal operations and perform their essential functions.The 2009 H1N1, a new virus was first detected in people in the United States and in the Dallas County area in April 2009. In Dallas County, H1N1 cases continued at low levels through the summer of 2009. Case rates increased in the fall to numbers above flu-seasonal levels. In spring 2009, DCHHS and its Public Health Preparedness Division began planning its multifaceted approach to administering H1N1 vaccines. DCHHS addressed the need to vaccinate the priority groups by launching phase 1 of its H1N1 vaccination plan. This plan would eliminate a large volume of residents seeking H1N1 vaccination from either clinic. DCHHS examined alternative strategies for distribution of vaccines then, decided to manage and operate a mass clinic using available physical space within its facility. To accomplish this task, DCHHS relied on the support services of Public Health Preparedness Department, Preventive Health Department, Childhood Immunization Department, Environmental Health Department, Housing Department, Dallas County Sheriff Department, MRC volunteers, Red Cross volunteers, and two staffing agencies. On Oct. 28, 2009 DCHHS announced that the H1N1 vaccine would be available to the public at the DCHHS location over a three day period (Nov. 4–Nov. 6) to uninsured Dallas County residents in the five priority groups outlined by the Centers for Disease Control and Prevention. In November 2009, the health department utilized its facility as the mass clinic site and implemented phase 1 of its multifaceted approach to administering H1N1 influenza vaccines while accomplishing the following objectives: 1) Over a period of three days, administer the H1N1 vaccine to 10,000 Dallas County residents, 2) Continue the essential delivery of public health services as it contributes to the continuity of operations for Dallas County communities, 3) Utilize three adjoining rooms, located on the sixth floor of the local health department’s facility, to conduct H1N1 mass vaccination, and 4) Over a period of three days, assign minimum internal trained and cross-trained county employees to perform roles and responsibilities in the clinic. Mass vaccination is not new to the field of public health. The 2009 H1N1 Administration Phase 1 is the first approach to how DCHHS responded to the administration of vaccines during this 2009 influenza season. To our knowledge, this is the first mass clinic operated, during normal business hours, within the health department’s facility. The 2009 H1N1 Vaccine Administration Phase 1 practice was the first mass clinic of its kind in Dallas County area. Although operating mass vaccination clinics for influenza is widely implemented by local health departments, no other local health departments have published this type of approach. These features distinguish the 2009 H1N1 Vaccine Administration Phase 1 practice from o

Dallas County Health and Human Services and its Public Health Preparedness Division played an essential role in this H1N1 vaccination event: 1) developed clinic layout and flow chart, 2) coordinated meetings with sheriff department and Red Cross, 3) established a system for requesting and tracking resources, and 4) utilized and organized the physical space in preparation for the mass clinic. Dallas County health department followed the Incident Command System to plan and operate the mass clinic: the Director of HHS performed the role and responsibilities of the Incident Commander. The planning team included our medical director, PHP assistant director, epidemiologists, PHP nurse supervisor, Preventive Health staff, and Childhood Immunization staff.

Cost for staffing $150,800. Total cost of supplies $12,289 (this includes additional medical supplies, office supplies, miscellaneous supplies, and janitorial supplies). DCHHS utilized its public health preparedness resources. American Red Cross provided food for clinic staff and volunteers. Texas Department of State Health Services allocated about 10,700 doses of the H1N1 vaccine to Dallas County Health and Human Services for vaccinating those most at risk. The Public Health Emergency Response-H1N1 Grant provided sufficient funding for the operation of the three-day clinic. DCHHS utilized its public health preparedness resources.

In Dallas County, H1N1 cases continued at low levels through the summer of 2009. Case rates increased in the fall to numbers above flu-seasonal levels. In spring 2009, DCHHS and its Public Health Preparedness Division began planning its multifaceted approach to administering H1N1 vaccines. When the H1N1 vaccine became available, DCHHS implemented phase 1 to vaccinate the five high-risk populations. In October 2009 DCHHS received over 10,700 doses from the state. The state provided funding for additional staffing. DCHHS utilized its public health preparedness resources. On October 28, 2009 DCHHS announced that the H1N1 vaccine would be available to the public at the DCHHS location over a three day period (Nov. 4–Nov. 6) to uninsured Dallas County residents in the five priority groups outlined by the Centers for Disease Control and Prevention. At the time of the first mass clinic the H1N1 virus continued to circulate at low levels. Majority of the H1N1 recipients were directed to the H1N1 clinic, located on the sixth floor of the DCHHS building. Pregnant women, individuals with special needs, and parents with baby carriages were directed to either Adult Immunization/Foreign Travel Clinic or Childhood Immunization Clinic. By directing these individuals to the immunization clinics we were able to conserve valuable space and time required to transport other priority groups to the sixth floor clinic. On Oct. 28, 2009 DCHHS announced that the H1N1 vaccine would be available to the public at the DCHHS location over a three day period (Nov. 4–Nov. 6) to uninsured Dallas County residents in the five priority groups outlined by the Centers for Disease Control and Prevention.

This was a one-time emergency response. As a result of the response we have a cross-trained, non-Public Health Preparedness staff. Sustainability through lessons learned—can carry over into other POD operations (single consent forms, handling of special needs, resource management, etc.). DCHHS now has a set of basic operating standards that can be utilized to supply and staff necessary operations during vaccination POD that are applicable to future public health emergencies where vaccine is the countermeasure. Texas Department of State Health Services continues to allocate doses of the H1N1 vaccine to Dallas County Health and Human Services for vaccinating Dallas County residents. The Public Health Emergency Response-H1N1 Grant provides sufficient funding for the next phases of the 2009 H1N1 Vaccine Administration operation.

Objectives were • Over a period of three days, administer the H1N1 vaccine to 10,000 Dallas County residents. • Continue the essential delivery of public health services as it contributes to the continuity of operations for Dallas County communities. • Utilize three adjoining rooms to conduct H1N1 mass vaccination. Over a period of three days, administer the H1N1 vaccine to 10,000 Dallas County residents.DCHHS envisioned vaccinating over 3,000 uninsured Dallas County residents each day. The SNS Coordinator conducted the following evaluations: Greeters Assessment Time Study, Forms Distribution Assessment Time Study, and Educator Assessment Time Study. Epidemiologists completed the throughput and situational awareness reports. Data collected every hour during clinic operations. Both the Incident Commander and the planning team received the data.The complaints made by the screeners surrounding the documentation process with the consent forms and vaccination cards created a rapid response to the revision of the assessment tools. The following changes were implemented prior to phase 2 of H1N1 vaccine administration: • Minimize paperwork by removing unnecessary documentation at the Screening Station. • Eliminate the bottleneck at the Registration table. • Improve client flow by reducing wait-time during the screening process in the mass clinics. A total of 10,194 doses administered during the three-day clinic, maximum wait time: 2 hours, minimum wait time: 15 minutes, maximum waiting in line: 754 residents, maximum hourly throughput: 743 Continue the essential delivery of public health services as it contributes to the continuity of operations for Dallas County communities.DCHHS announced via the media that the Dallas County Health and Human Services building will continue all public health-related functions during the operation of the H1N1 three-day clinic.All department heads kept the Incident Commander up to date on department’s performance.The Incident Commander was available to address any concerns and issues of department heads during each day of the clinic operations.Both immunization clinics provided uninterrupted services and administered H1N1 vaccines to pregnant women, individuals with special needs, and parents with baby carriages. Over a three day period, 248 residents visited the Childhood Immunization Clinic for immunization services (not including H1N1 vaccination). A total of 40 clinicians provided vaccines: DCHH staff, Medical Reserve Corps, and one staffing agency contributed to the clinic staffing. Utilize three adjoining rooms, located on the sixth floor of the local health department’s facility, to conduct H1N1 mass vaccination.In spring 2009, DCHHS and its Public Health Preparedness Division began planning its multifaceted approach to administering H1N1 vaccines. When the H1N1 vaccine became available, DCHHS implemented phase 1 to vaccinate the five high-risk populations by using three adjoining rooms (estimating measurements of 32' x 105' 1") located within the local health department’s building: 32’ x 39' 10" (Room A), 32' x 40' 10" (Room B), and 32' x 26' 1" (Room C).Greeters Assessment Time Study, Forms Distribution Assessment Time Study, and Educator Assessment Time Study. Epidemiologists completed the throughput and situational awareness reports. Data collected every hour during clinic operations. Both the Incident Commander and the planning team received the data.Two of the three elevators were designated for transporting H1N1 recipients to and from the sixth floor clinic. Residents moved to various checkpoints on the first floor, then escorted to one of two designated elevators, before being transported to the H1N1 clinic located on the sixth floor. These simplified paths contributed to short waiting times and elimination of bottlenecks. Majority of the H1N1 recipients were directed to the H1N1 clinic, located on the sixth floor of the DCHHS building. Pregnant women, individuals wit